Download Outbreak Management Guidelines for Health Care Facilities

OUTBREAK
MANAGEMENT
Guidelines for Health Care
Facilities
Prepared by: Niagara Region Public Health
Infectious Disease Program and Environmental Health
Division
“Dedicated to Achieving a Healthier Niagara”
TABLE OF CONTENTS
Contact Information ............................................................................................................ 2
Introduction ......................................................................................................................... 3
Upper Respiratory Outbreak
1.1
Education ................................................................................................................ 4
1.2
Policy Preparation ................................................................................................... 5
1.3
Surveillance – Line Listing Form ........................................................................... 6
(Sample) Completing An Outbreak Line List ................................................... 8
1.4
Outbreak Definition ................................................................................................ 9
(Sample) Outbreak Management Summary Checklist ................................... 10
1.5
Case Definition ..................................................................................................... 11
1.6
Specimen Collection – Nasopharyngeal Swabs .................................................... 12
1.7
Control Measures .................................................................................................. 15
Respiratory Outbreak Control Measures ........................................................ 19
1.9
Declaring Over ...................................................................................................... 20
1.10 Influenza Outbreaks .............................................................................................. 21
Recommended Policy Statement For Influenza Outbreak .............................. 23
Websites With Information About Influenza .................................................. 27
1.11 Respiratory Outbreak Associated Organisms: ...................................................... 26
A Reference Chart For Health Care Workers
Enteric Outbreak
2.1
Surveillance – Line Listing Form ......................................................................... 28
2.2
Outbreak Definition .............................................................................................. 29
(Sample) Outbreak Management Summary Checklist ................................... 30
2.3
Case Definition ..................................................................................................... 31
2.4
Specimen Collection ............................................................................................. 32
Labelling An Enteric Outbreak Kit ................................................................. 33
2.5
Food Sampling Guidelines .................................................................................... 35
2.6
Control Measures .................................................................................................. 36
Enteric Outbreak Control Measures................................................................ 39
2.7
Declaring Over ...................................................................................................... 40
2.8
Enteric Outbreak Associated Organisms: ............................................................. 41
A Reference Chart For Health Care Workers
APPENDIX
Hand Hygiene Using Hand Rubs
Hand Hygiene With Soap And Warm Water
Putting On Personal Protective Equipment (PPE)
Taking Off Personal Protective Equipment (PPE)
What You Need To Know About Outbreaks
Sample Transfer Letter
Sample Letter To Physicians
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Outbreak Management
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REVISED October 2012
CONTACT INFORMATION
Niagara Region Public Health staff can assist you by telephone or by facility visit with
information regarding management of an enteric or upper respiratory outbreak. If you
suspect an outbreak in your facility, contact Niagara Region Public Health at 905688-8248 ext. 7330/7554, 24 hours a day.
For after hours (Monday to Friday 4:30 pm – 8:30 am, Saturday, Sunday and
holidays) follow the emergency instructions on the voice automated message and
contact the dispatch phone number 905-984-3690.
Environmental Health Division
Infectious Disease Program
Program Managers:
Heather Hague
Lois Lacroix
x7329
x7553
Team Leaders:
Sandra Jacobs
Lorrie Ross
x7333
x7391
Public Health Nurses:
Yvonna Cahill
x7435
Sandy Crayford
x7474
Linda Green
x7388
Megan Height
x7387
Danya Huneault
x7447
Martha Jespers
x7557
Pamela Lof
x7551
Cathy Martin
x7326
Sandra Romagnoli
x7346
Angela Roy
x7551
Jennifer Sharron
x7346
Linda Warkentin
x7558
Dayna Young
x7115
Health Promoter:
Tracy Haley
Program Manager:
Dave Carey
x7417
Public Health Inspectors:
Sam DiMeo
Melania Iancov
Bruce Lance
Rick Legge
Sobaan Afzal
Health Promoter:
Rob Levay
x7214
x7628
x7270
x7456
x7290
x7385
x7341
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REVISED October 2012
INTRODUCTION
The purpose of this guide is to facilitate the investigation of respiratory and enteric
outbreaks in health care facilities. Effective management of outbreaks in health care
facilities is challenging. Early recognition of outbreaks, rapid initiation of control
measures and effective communication are critical for minimizing the extent of an
outbreak. To ensure effective outbreak management, all information must be exchanged
with designated contacts and must be documented carefully, particularly in the early
stages of an investigation.
The objectives of this guide are:
To assist facilities prevent outbreaks of respiratory and enteric disease
To assist facilities develop a surveillance system to monitor respiratory and enteric
illness and identify early outbreaks
To assist facilities collaborate with Public Health in investigating and managing
outbreaks of respiratory and enteric infections including:
 Consulting promptly with Public Health when there is suspicion of an outbreak
 Activating an Outbreak Management Team (OMT)
 Ensuring that OMT members understand their roles and responsibilities
 Outlining outbreak control measures
 Ensuring collection of appropriate specimens in a timely manner to verify
diagnosis
 Updating information regarding changes to recommendations or procedures as
needed
The following manual provides consensus opinion of several resources including:
1. National Advisory Committee on Immunization: http://www.phacaspc.gc.ca/naci-ccni/
2. Public Health Laboratory, A Guide to the Control of Enteric Disease Outbreaks in
Health Care Facilities, 1993
3. A Guide to the Control of Respiratory Disease Outbreaks in LTCF – Public
Health Branch & Long Term Care Homes Branch, MOHLTC, 2004
http://www.health.gov.on.ca/english/providers/pub/pubhealth/ltc_respoutbreak/ltc
_respoutbreak.pdf
4. Provincial Infectious Diseases Advisory Committee (PIDAC) Knowledge
Products (best practice documents)
http://www.oahpp.ca/resources/pidac-knowledge/index.html
It is our intent to review these recommendations periodically as new knowledge becomes
available, both in the literature and from our local experiences. Users of this manual are
invited to communicate their views, experiences, problems and improvements so that
these may be addressed in the future.
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1.1
EDUCATION
Ongoing education of staff, volunteers, residents and residents’ families about infection
prevention and control, and outbreak management policies must be part of an effective
Infection Control Program.
Topics for consideration in education programs for all staff and residents are:
Surveillance of Infections
Hand Hygiene
Routine Practices and Personal Protective Equipment (PPE); e.g. appropriate use of
gloves, gowns, eye protection, and masks (N95/surgical)
Specimen Collection (How to obtain a Nasopharyngeal Swab; How to Collect an
Enteric Stool Specimen)
Environmental Cleaning and Sanitation
Respiratory/Enteric Outbreak Control Measures
Influenza Immunization and Exclusion Policy During Confirmed Influenza Outbreaks
Public Health Nurses from the Infectious Disease Program and Public Health Inspectors
from the Environmental Health Division are available to assist your facility in providing
education to staff, volunteers, residents and families.
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1.2
POLICY PREPARATION
Each facility must have a policy to address respiratory disease surveillance, prevention
(including annual influenza immunization) and outbreak control. These policies must be
based on current guidelines available from the Ministry of Health and Long-Term Care,
the local public health unit, and PIDAC Best Practice Guidelines.
Policies should address the following topics:
Procedures for surveillance, early recognition for potential infectious conditions and
management of an outbreak including the composition and mandate of the Outbreak
Management Team (OMT)
Process to rapidly access specimen kits, testing, and results of laboratory tests in the
event of a suspect outbreak
Ensuring that at least one nursing staff is available daily who is competent in the
appropriate technique for the collection of nasopharyngeal specimens
Exclusion policy for unimmunized staff members during an influenza outbreak
Staffing contingency plan addressing varying levels of available staff due to failure to
immunize, unwillingness or contraindication to antiviral agents or illness
A policy on use of antiviral medications during confirmed influenza outbreaks.
Oseltamivir (TAMIFLUTM) as first line of defense.
Obtaining consent for prophylaxis with antivirals from residents or substitute
decision-makers
Obtaining pre-approved orders from physicians or a “medical directive” signed by the
Medical Director for antiviral prophylaxis
Establishing lines of communication between the facility, health unit, and laboratory
Ongoing effective communication with residents, families of residents, staff, and
media
Annual review of policies related to outbreak prevention and control
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REVISED October 2012
1.3
SURVEILLANCE – LINE LISTING FORM
See attached line listing forms, and sample on “Completing an Outbreak Line List”:
LTCF – Respiratory/Enteric
Acute Care – Respiratory/Enteric (Residents)
Acute Care – Respiratory/Enteric (Staff)
Surveillance is an essential component of an effective infection prevention and control
program. Surveillance is the ongoing systematic collection, collation, analysis and
interpretation of data; and the dissemination of information to those who need to know in
order that action is taken. Surveillance establishes baseline information about the
frequency and types of infections that exist in a health care facility. This information can
be used to determine deviations from baseline.
An important goal of surveillance is to ensure early identification of a potential outbreak
or an outbreak in its early stages so that control measures can be instituted as soon as
possible. A designated, trained Infection Control Professional should be responsible for
surveillance and outbreak management activities. In their absence, a competent person
must be designated to continue these functions, including on weekends and during
holiday periods. Surveillance should be done for both resident and staff populations,
however, it is recognized with current resources many LTCFs are unable to conduct
active staff surveillance year round. In an effective Infection Control Program, staff
surveillance is also recommended.
Resident Surveillance
Continuous facility-wide surveillance is useful to establish baseline levels of infection
throughout the year. Potential outbreaks are recognized when infection rates increase
above the baseline. It is important that LTCFs are also able to recognize outbreaks
during off-hours (weekends, holidays). Targeted surveillance for respiratory symptoms
should be enhanced during the influenza season (November to April) and when influenza
activity has been reported in the local community. All staff providing direct care must be
aware of the symptoms of respiratory illness, the criteria for a suspected outbreak and the
procedures for reporting to the ICP.
Facilities are required to have ongoing surveillance programs to determine the presence
of infections. Key features of these programs shall include:
A sufficiently sensitive surveillance program to identify sentinel events and
trends
Analysis of surveillance data by the ICP in order to trigger actions to reduce
or eliminate transmission of infection
Surveillance strategies that take community disease prevalence and the unique
epidemiology of infection in long term care into account
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Staff Surveillance
The Ontario Hospital Associate states “HCWs have a responsibility to their residents and
colleagues regarding not working when ill with symptoms that are likely attributable to
an infectious disease. This includes staff with influenza-like illness, febrile respiratory
illness, gastroenteritis and conjunctivitis.
All employees should be educated on the importance of reporting illness (including colds,
influenza, diarrhea or when the cause is unknown etc.). Staff should be reminded that
staying home will reduce the spread of infection within the facility. All employees are
responsible for promptly reporting any infections they have, or may have come into
contact with to their supervisor. This step is very important in preventing the infection
from spreading to residents.
Methods of Surveillance
Daily surveillance is the most effective way to detect respiratory infections. There are
two methods to conduct daily surveillance: active and passive.
i.
Passive Surveillance
Passive surveillance involves looking for infections while providing routine daily care or
activities. Residents with respiratory and other symptoms should be noted on the daily
surveillance form. This form should be easy to use and include patient identification and
location, date of onset, a checklist of relevant signs and symptoms, including fever,
diagnostic tests and results when available. The completed form should be forwarded to
the ICP on a daily basis. Any suspected outbreak should be reported immediately to the
ICP. It is important to maintain a high index of suspicion for respiratory infections,
especially during flu season (November – April).
ii.
Active Surveillance
Active surveillance involves seeking out residents with symptoms of an infection. Several
strategies may be used including:
Conduct Unit rounds; receive verbal report from Unit staff of clinical
observations
Chart review of medical and/or nursing progress notes which may note fevers
Review Unit reports, and physician/staff communication books
Review laboratory reports and pharmacy antibiotic utilization records
All available sources of information within the facility may contribute to the surveillance
activities. The method used by each facility should be practical in that setting. Analysis
of data collected should be performed by the ICP or designate. Results of surveillance
data should be reviewed on a regular basis to determine whether these meet the criteria
for infection in each resident and if a suspected outbreak exists.
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REVISED October 2012
(SAMPLE) COMPLETING AN OUTBREAK LINE LIST
It is important to complete facility name, outbreak number and date declared on each
sheet submitted to ensure they are not mixed in with other outbreaks.
Provided by
Public Health
Earliest date
symptoms began
Tick all that are
appropriate and meet
case definition
Date of case’s last
influenza and
pneumococcal
vaccination
Number in
sequence. Do
not change
without
consulting
Public Health
nurse
Indicate resident
or staff
Niagara Region Public Health
Outbreak Management
Include
important
additional
information
Date specimen
collected
8
Lab will give
results to
Public Health
Date symptoms ended
REVISED October 2012
1.4
OUTBREAK DEFINITION
An outbreak should be suspected anytime that illness exceeds the normal baseline
distribution in a given area, at a given time. Reporting of respiratory infection outbreaks
is legislatively required under the Health Protection & Promotion Act (HPPA) from the
following institutions: nursing homes, homes for the aged, acute and chronic care
hospitals operating under the Public Hospital Act. Although not required under the
HPPA, reporting of respiratory infection outbreaks in retirement homes is strongly
recommended.
Suspect an outbreak whenever there are:
Two or more cases of acute respiratory symptoms occurring within 48 hours, in one
geographic area. Symptoms may include:
- abnormal temperature
- dry cough (new)
- productive cough (new)
- runny nose/sneezing
- nasal congestion/stuffy nose
- sore throat
- hoarseness/difficulty swallowing
- chills
- myalgia
- malaise
- headache
- decreased appetite
Criteria for a potential influenza outbreak:
o
one laboratory confirmed case of influenza OR
o
two cases of influenza-like illness occurring with 48 hours in a geographic
area (i.e., unit, floor) OR
o
more than one unit having a case of acute respiratory illness with 48 hours
Note: The clinical presentation of influenza in an elderly, fully immunized population
can differ from the usual clinical presentation of influenza. Because influenza in the
elderly often causes tiredness (malaise), muscle aches (myalgia), loss of appetite,
headache, and chills. In the elderly, fever could be absent or manifest as follows:
abnormal temperature for the resident or a temperature <35.5 oC or >37.5oC.
An outbreak can be declared at any time by the Medical Officer of Health, or their
designate, or the ICP or designate for the LTCF. There should be a discussion between
the Medical Officer of Health or designate and the facility regarding whether to declare a
facility-wide outbreak or unit specific outbreak when the cases are on one unit and can be
confined to that unit.
See: Sample Outbreak Management Summary Checklist
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REVISED October 2012
(SAMPLE) OUTBREAK MANAGEMENT SUMMARY CHECKLIST
CHECKLIST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Notify charge RN, Infection Control Practitioner or Director of Resident
Care or Associate Director of Resident Care.
For evenings and weekends, notify the manager on-call.
Initiate a line listing of all symptomatic patients/residents/staff using the
Public Health line list form.
Notify Public Health, Infectious Disease Program 905-688-8248 ext. 7330
or after hours 905-984-3690. Have the following information available:
Date of onset / Signs and symptoms
Total # of patients/residents/staff on unit and/or facility
Total # of patients/residents/staff ill at present
Total # of patients/residents/staff immunized against influenza
(for upper respiratory outbreaks only)
Enteric/nasopharyngeal swab kits on hand (check expiry date)
Have Outbreak Management Manual available for reference.
Obtain an outbreak number.
Establish outbreak case definition.
Implement outbreak control measures. Refer to Outbreak Management
Manual for specific respiratory or enteric outbreak control measures.
Place outbreak signs in appropriate areas:
□ Front entrance
□ Stairwells/Elevators
□ Outbreak unit
Cohort and isolate symptomatic patients/residents and place proper
signage on door of room.
Cohort staff.
Collect and refrigerate nasopharyngeal swab or enteric specimens as
directed by Public Health. Contact Infectious Disease Program for
pickup.
Notify:
□ Medical Advisor/MRP physician for facility
□ Administrator
□ Housekeeping
□ Dietary
□ Pharmacy
□ O.T., P.T., Recreation Therapy, Volunteer Co-ordinators
□ Pastoral Care
Notify other units of outbreak and heighten surveillance ill
patients/residents.
Educate patients’/residents’ family members of limited visitation,
adherence to outbreak control measures and appropriate use of PPE if
needed.
Fax the line listing daily to Public Health, Infectious Disease Program
905-682-6470.
For confirmed Influenza Outbreaks refer to Influenza Outbreak
Management Guidelines section of the Outbreak Management Manual.
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Outbreak Management
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Nurse
Initial
REVISED October 2012
1.5
CASE DEFINITION
Different respiratory viruses often cause similar acute respiratory symptoms. As a result,
each respiratory outbreak requires its own case definition. The case definition should
be developed for each individual outbreak based on its characteristics. The case
definition should also be reviewed during the course of the outbreak, and modified if
necessary, to ensure that the majority of cases are captured by the definition.
A Case Definition Example:
“Any resident or staff presenting with two or more of the following symptoms: fever,
sore throat, cough and runny nose.”
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1.6
SPECIMEN COLLECTION – NASOPHARYNGEAL SWABS
Once the outbreak has been declared, your facility will be assigned an outbreak number
that will be used to identify all lab specimens collected for testing.
The outbreak number is:
2246 - 201X - three digit number
(Health Unit - Year - Outbreak Number)
Specimen collection is critical to determining the causative agent in each respiratory
outbreak. Ensure that staff is familiar with the procedure for the collection of
nasopharyngeal swabs. See “Nasopharyngeal Specimen Collection Technique” attached.
Check with Public Health staff regarding available to assist with education of staff on this
procedure (i.e., videos).
Note: Consult with your Medical Director prior to collecting nasopharyngeal (NP) swabs.
To identify the causative agent:
1) It is best to collect nasopharyngeal specimens as early as possible from the most
acutely ill residents and staff, preferably within the first 48 hours of onset of
symptoms.
2) If possible, 5 specimens only should be obtained initially. Further specimen
collection will be determined based on results and progress of outbreak.
3) Staff obtaining specimens must ensure correct labeling of specimens to ensure testing
by Public Health Lab. This includes the name of the case, date of birth, and the
outbreak number on the nasopharyngeal specimen vial and requisition form. See:
“How to Complete Public Health Lab Test Requisition Form” attached.
4) Nasopharyngeal specimens must be refrigerated after collection until pick up and
transport to the lab to ensure optimal results.
5) Notify the Public Health Infectious Disease program that specimens are ready for
pick-up.
Note: once a causative organism is identified, no further collections of nasopharyngeal
specimens are recommended. For further testing, consult with Public Health.
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NASOPHARYNGEAL SPECIMEN
COLLECTION
Nasopharyngeal swab method for
respiratory virus detection
Anterior naris
Mid-inferior portion
of inferior turbinate
Posterior pharynx
Patient's head
should be inclined
from vertical to
about 70%
The laboratory needs high levels of organism to
culture successfully for
respiratory viruses such as RSV, influenza
A & B virus or parainfluenza virus.
A properly taken nasopharyngeal swab
will yield high levels of organism.
Ensure the following equipment is available:




NP Swab kit from Public Health
Gloves
Mask
Goggles
1.
2.
3.
4.
5.
6.
Insert nasopharyngeal swab into one nostril.
Press the swab tip on the mucosal surface of the mid-inferior turbinate.
Briefly rotate the swab once it has been inserted.
Leave swab in place for a few seconds to absorb material.
Withdraw swab and insert into transport medium.
Break swab shaft at scored line to fit in tube well below the cap, and replace cap to vial, closing
tightly.
7. Refrigerate the specimen
8. Fill out Public Health Laboratory requisition form completing all sections:

Health Card number

Agency Name and outbreak number

Tests requested: V23 (influenza A/B)

Specimen type and site: Nasopharyngeal Swab

Reason for test: to diagnose disease

Clinical information: symptoms
9. Contact Public Health Infectious Disease Program at 905-688-3762 x7330 for pick up of nasopharyngeal
specimens as soon as possible after collection - after hours please call
dispatch 905-984-3690
N.B. Rule of thumb to determine when swab is placed properly: Insert swab to
one half the distance from the tip of the nose to the tip of the earlobe.
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HOW TO COMPLETE PUBLIC HEALTH LABORATORY TEST
REQUISITION
Resident Health Card
Resident Gender
Resident Date of Birth
yy/mm/dd
Resident FIRST NAME
Resident LAST NAME
Facility Name
Address
Phone Number
Outbreak Number
Provided by Niagara
Region Public Health
Enter Test Code V23
(Influenza A/B)
Date Specimen Collected
Onset Date
Specimen Type
Check appropriate
box(s)
Leave This Area Blank
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1.7
CONTROL MEASURES
Facilities that suspect they have an outbreak should implement initial outbreak control
measures to prevent further spread of illness. Facilities should consider establishing an
Outbreak Management Team and meet regularly including all representatives who
have decision making authority in the facility. Members should include:
Medical Advisor/Director
Administrator
Director of Nursing/Director of Resident Care
Infection Control Officer/Infection Control Nurse
Public Health Nurse/Public Health Inspector
Housekeeping/Laundry Supervisor
Food Services Supervisor
Recreational Activities Supervisor
Pharmacist
The following control measures are recommendations from Public Health:
1. Isolation of Symptomatic Cases
Restrict cases (ill residents) to their room until 5 days after the onset of acute
illness or until symptoms have completely resolved (whichever is shorter). For
some pathogens the periods of communicability may be longer than 5 days, but
for practical reasons, this could be applied to outbreaks caused by respiratory
viruses other than influenza.
Implement droplet precautions (i.e., post signs)
http://ricn.on.ca/photos/custom/CSICNfiles/Droplet%20STOP%20Sign_Front%20&%20Back.pdf
Restriction of ill residents to their room is recommended as long as it does not
cause the resident undue stress or agitation and can be done without applying
restraints.
2. Cohorting Residents/Staff
Cohorting is defined as the grouping together of individuals in a specific area to limit
the contact between infected cases and non-infected cases, in order to decrease
opportunities for transmission of infectious agents.
If cases are confined to one unit, all residents from that unit should avoid contact with
residents in the remainder of the facility.
If possible, exposed staff should remain caring for symptomatic cases on a daily basis
and avoid transferring to another unit/floor during the outbreak.
During non-influenza outbreaks, discuss the possibility of one staff member looking
after only ill residents and others looking after only well residents. Alternatively,
discuss the possibility of keeping staff members working on only one unit if possible.
Attempts should be made to minimize movement of staff, students, or volunteers
between floors/wings especially if some units are unaffected. These measures should
not be required during influenza outbreaks where all persons are immunized or on an
appropriate antiviral drug.
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REVISED October 2012
Allied health professionals (e.g., respiratory therapists, physiotherapists, occupational
therapists, speech therapists, recreational therapists) should be cohorted to the
outbreak unit where possible, or provide care on non-outbreak units before entering
the outbreak unit (preferably on a one-on-one basis)
3. Hand Hygiene
Hand hygiene stations should be set up at designated areas in the facility (i.e.,
entrances, outside elevators, patient/resident care areas)
Hand hygiene should be performed:
o Before initial patient/resident or patient/resident environment contact
o Before sterile procedures
o After body fluid exposure risk
o After patient/resident or patient/resident environment contact
Alcohol based hand rubs (ABHR) are the first choice for hand hygiene in clinical
situations when hands are not visibly soiled. Using ABHRs is more effective than
washing hands (even with an antibacterial soap) when hands are not visibly soiled.
When visible soil is present and running water is not immediately available, use
moistened towellettes followed by ABHR.
Residents, staff and volunteers should be instructed in proper hand hygiene to
facilitate staff and visitor hand hygiene
Refer to Appendix: “Hand Hygiene using Hand Rubs”.
4. Masking/Gowning/Gloving/Eye Protection is Recommended for Direct Patient
Care of Ill Residents
The use of surgical masks, gowns, and gloves is recommended for direct patient care
of ill residents during an outbreak to prevent transmission of organisms.
Staff wearing masks must remove their mask before caring for another resident, and
when leaving the residents dedicated space/room.
Visitors do not need to wear gloves or masks if they are visiting one resident only;
however, if providing direct patient care to an ill resident they should be encouraged
to wear gown, surgical mask and gloves.
Eye protection/safety glasses, goggles and face shields should be worn when there is
a potential for splattering or spraying of blood, body fluids, secretions/excretions,
including cough producing aerosol generating procedures while providing direct
resident care (i.e., collection of NP swab). Personal eyewear is not sufficient.
Refer to Appendix: “Sequence for Donning and Removing Personal Protective
Equipment.”
5. Enhanced Environmental Cleaning/Sanitizing
Ensure cleaning and sanitizing of environmental surfaces frequently contaminated by
residents/staff (i.e., hand rails, door knobs, bathroom units, furniture).
Ensure a process for proper disposal of contaminated materials; double bagging of
waste is not required.
Cleaning and sanitizing methods should be reviewed by Public Health Inspector.
Disposable dishes and cutlery are not required.
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REVISED October 2012
6.
7.
8.
9.
Refer to: PIDAC Best Practices for Environmental Cleaning for Prevention and
Control of Infections and Best Practices for Cleaning, Disinfection and
Sterilization of Medical Equipment/Devices
Exclusion of Symptomatic Staff from Work/Facility
Staff who meet case definition are excluded from the facility for 5 days from onset of
symptoms or until asymptomatic, whichever comes first; if the causative agent is
known, other measures may apply.
For a confirmed influenza outbreak, ill staff, students or volunteers taking antiviral
medication for treatment (not prophylaxis) shall be excluded from work for 5 days
from onset of symptoms or until symptoms have resolved, whichever is shorter.
Limited Visiting
Any symptomatic (potentially infectious) visitors should be excluded at anytime,
especially during influenza season.
Signs should be posted in the facility indicating that there is an outbreak and visitors
should be warned that they may be at risk of acquiring infection within the facility.
During an outbreak, visitors should visit only their own friend/relative, in their own
room (not in a common area), and should wash their hands before and after the visit
at hand hygiene stations in the facility. See Appendix: “What You Need to Know
About Outbreaks”.
Public Health does not recommend closing the facility to visitors/volunteers; only in
the case of extremely virulent disease would the Medical Officer of Health order the
facility to be closed to the public.
Suspension of Social Activities
As much as possible, all social activities should be restricted to each respective unit.
The Outbreak Management Team must find a balance between restricting activities to
control the spread of infection, and providing therapeutic opportunities from social
activities.
Visitation by outside groups (e.g., entertainers, meetings, community groups, etc.) is
not recommended. Also, visitation of multiple residents is not recommended.
Onsite adult and childcare programs may continue provided there is no interaction
between residents and participants of the program.
Restrict New Admissions, Re-Admissions and Transfers
Restricting admissions unnecessarily will create a backlog in acute care or other
community facilities; on the other hand, admitting persons who are susceptible into
an outbreak situation poses a risk to their health.
Residents can be transferred from the outbreak facility to a hospital with prior
notification to Hospital Infection Control Officer or designate.
Residents admitted from the outbreak facility to hospital with respiratory illness
can be re-admitted to the LTCF at any time, provided that appropriate
care/accommodation can be given.
New admissions (from community), residents admitted to hospital prior to the
outbreak, or admitted to hospital for reasons other than respiratory illness may
be admitted/re-admitted to the LTCF if the following conditions are met:
a) the resident or substitute decision-maker has been informed of the outbreak status
and provided consent;
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REVISED October 2012
b) the resident’s physician has been informed of the outbreak status and provided
consent (taking into consideration the severity of the particular outbreak relative
to the resident’s condition)
c) if the outbreak is due to influenza, the resident is protected from influenza by
vaccination and an anti-viral drug
Resident transfers from anywhere in the facility to another Long Term Care facility is
not recommended during an outbreak. Possible exception of this recommendation
should be discussed with the Medical Officer of Health on an individual basis.
Note: A resident’s bed will be kept for up to 30 days while he/she receives treatment in
an acute care facility, or 60 days for psychiatric leave. In the event that a resident’s
hospital stay exceeds 30 days due to a closure of a long term care facility because of an
outbreak, the Ministry of Health and Long-Term Care will extend the period for time the
resident may remain away from the facility.
10. Advise Hospital Infection Control Staff of Outbreak Prior to Transferring a
Resident
Prior to transfer of residents to hospital, designated staff at the outbreak facility
should contact the Infection Control Professional directly by phone to inform them
that the resident is coming from an outbreak situation.
Inform them of the outbreak, the pathogen if known, and if the resident is
symptomatic or not.
For influenza outbreaks only, complete outbreak notification form to provide required
information and send with resident on transfer to hospital. See Appendix: Transfer
Letter.
11. Working at Other Facilities
During respiratory outbreaks, staff/volunteers should not work at any other facility.
If asymptomatic staff choose to work at another facility, they must wait one
incubation period (i.e., 72 hours) after working the last shift at the outbreak facility (if
the causative organism is known, the waiting period may differ). Staff working at 2
facilities must inform the receiving DOC (Director of Care) or designate at the nonoutbreak facility.
During an Influenza A or B outbreak, previously immunized staff (> 2 weeks prior to
outbreak) have no restrictions on their ability to work at other facilities, provided the
individual changes their uniform between facilities. However, unimmunized staff
must wait one incubation period (72 hours) from the last day they worked at the
outbreak facility prior to working in a non-outbreak facility, to ensure that they are
not incubating influenza.
Note: If influenza isolates that have been strain characterized indicate a different
lineage than is contained in the influenza vaccine for the current season,
recommendations for staff working at other facilities may vary from above.
12. Medical Appointments
Non-urgent appointments made before the outbreak shall be rescheduled.
Niagara Region Public Health
Outbreak Management
18
REVISED October 2012
RESPIRATORY
OUTBREAK CONTROL
MEASURES
The following control measures are in force until further notice:

Isolation of symptomatic cases

Cohorting residents/staff

Hand Hygiene

Masking, gowning, gloving and eye protection (when
appropriate) is recommended for direct patient care of
ill residents

Enhance environmental cleaning and sanitizing

Exclusion of symptomatic staff from work

Limited visiting

Suspension of social activities

Restrict new admissions, re-admissions & transfers

Advise Hospital Infection Control Staff of the outbreak
prior to transferring a resident/patient

Staff/volunteers should not work at another health
care facility
Niagara Region Public Health
Outbreak Management
19
REVISED October 2012
1.9
DECLARING OVER
The length of time from the onset of symptoms of the last case until the outbreak is
declared over can vary and is dependent on whether the last case was a resident/patient or
staff. Prior to declaring an outbreak over, the facility must not have experienced any new
cases of infection (resident or staff) which meet the case definition for the period of time
as defined by the Outbreak Management Team (OMT). As a general rule, respiratory
outbreaks (e.g. Influenza) can be declared over if no new cases have occurred in 8
days from the onset of symptoms of the last resident/patient case.
Note: For other respiratory organisms that may be isolated during the outbreak,
discussion should be held with Public Health to determine when outbreak will be
declared over.
The rationale for this definition is, if the outbreak were continuing, given active
surveillance, new cases would have been identified within 8 days since 8 days is the outer
limit of the period of communicability of influenza (5 days) plus one incubation period (3
days). Note: if symptoms in the last resident/patient case resolve sooner than 5 days, or if
the last case is a staff member who should stay at home during the period of
communicability, the time until the outbreak is declared over can be shortened
accordingly. Since large LTCFs tend to have some sporadic influenza or respiratory
infection cases in non-outbreak situations, the OMT may need to attempt to differentiate
between these sporadic cases and outbreak-associated cases in identifying the last
outbreak related resident case.
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Outbreak Management
20
REVISED October 2012
1.10
INFLUENZA OUTBREAKS
(i)
PREVENTION – INFLUENZA IMMUNIZATION
Vaccination is recognized as the cornerstone for preventing or attenuating
influenza for those at high risk of serious illness or death from influenza
infection and related complications.
Health care workers and their employers have a duty to actively promote,
implement and comply with influenza immunization recommendations in
order to decrease the risk of infection and complications in the vulnerable
populations for which they care. Educational efforts aimed at health care
workers and the public should address common doubts about disease risk for
health care workers, their families and patients, vaccine effectiveness and
adverse reactions.
The provision of influenza vaccination for health care workers who have
direct patient contact is an essential component of the standard of care for the
protection of their patients. Health care workers who have direct patient
contact should consider it their responsibility to provide the highest standard
of care, which includes annual influenza vaccination. In the absence of
contraindications, refusal of health care workers who have direct patient
contact to be immunized against influenza implies failure in their duty of care
to patients (Source: CCDR http://www.phac-aspc.gc.ca/naci-ccni/ ).
LTCFs should:
□ Ensure that all staff are provided with information annually regarding the
influenza vaccine and exclusion policy
□ Promote and implement accessible influenza vaccination clinics
□ Keep an updated record of all resident and staff influenza immunizations
and update list throughout the influenza season.
□ Report immunization status among residents, staff, and volunteers to the
local medical officer of health by the outlined date provided by the
MOHLTC.
□ Advise outside agencies that provide staff to the LTCF of the facility’s
immunization/exclusion policy
□ Develop a staffing contingency plan based on immunization rates in their
facility
(ii)
RECOMMENDED POLICY STATEMENT – Influenza Outbreaks
In order to protect vulnerable patients during an outbreak, it is reasonable to
exclude from direct patient contact those health care workers with confirmed
or presumed influenza, and unvaccinated health care workers who are not
receiving antiviral prophylaxis.
Facilities should have an Exclusion Policy for use for staff and volunteers who
choose not to be immunized and/or take antiviral drugs.
Things to consider or include in the development of Exclusion policy:
How and when the exclusion policy comes into effect
Who falls under the definition of staff
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Outbreak Management
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REVISED October 2012
Hierarchy of immunization status, and what to do at each step
Consequences of failure to comply
Managing shared staff working in a facility with a declared outbreak
Length of exclusion time clearly defined when staff are on an antiviral drug
How to verify staff are taking the antiviral
How staff will be educated and update re: policy
Obtaining antiviral prescription pre-season
Define HR issues, e.g., time off designation, cost of anti-virals.
See sample “Recommended Policy Statement for Influenza Outbreaks” attached.
Residents
Prior to, or upon admission, each resident should be assessed regarding vaccination and
medical status. Based on this assessment, informed consent from the resident or
substitute decision-maker should be obtained for influenza and pneumococcal vaccines,
and antiviral drugs for influenza prophylaxis in the event of an outbreak.
Immunity after influenza vaccination usually lasts less than 1 year. However, in the
elderly, antibody levels may fall below protective levels in 4 to 6 months. To ensure that
protection lasts throughout the influenza season, the recommended time for influenza
immunization is from October to mid-November unless otherwise advised by your local
public health unit. If the resident is admitted after the facility’s fall vaccination program
and before the influenza season is over (usually late March), vaccination must be offered,
unless the person has already received the current season’s influenza vaccine.
If the influenza immunization status of a resident is not available or unknown, the
resident should be considered unvaccinated, and vaccination should be given.
The immunization record of the resident should be retained in a readily accessible part of
their health record. Upon transfer, the resident’s recent immunization status should be
shared with the receiving Health Care facility.
Staff
Annual immunization against influenza should be required for all persons carrying on
activities in the LTCF unless medically contraindicated. Influenza immunization may be
received at the annual influenza clinic or from any other private health care provider. All
staff who receive the influenza vaccine from a source other than the LTCF must provide
proof of influenza immunization.
Only the following should be accepted as proof of influenza immunization:
A personal immunization record documenting receipt of the current season’s
influenza vaccine signed by a health care professional
A signed physician’s note indicating immunization
Documented immunization from another facility or institution
If this documentation is not available, the LTCF should not consider the staff member
immunized, and the employer must offer influenza immunization to the person.
Niagara Region Public Health
Outbreak Management
22
REVISED October 2012
RECOMMENDED POLICY STATEMENT FOR INFLUENZA OUTBREAKS
Policy:
(Name of facility) has an established protocol for staff during a confirmed influenza
outbreak that complies with the recommendations of Niagara Region Public Health.
Purpose:
To ensure the residents and workers are protected from possible exposure to and
transmission of influenza during an influenza
outbreak.
Positive Isolate of Influenza A and/or B
Staff** immunized >2 weeks
prior to outbreak
Staff not immunized: options
1. Take antivirals AND receive flu vaccine
and return to work; antiviral needs to be
taken for 2 weeks minimum or until
outbreak is declared over, whichever
comes first
May continue to work as long
as not symptomatic with flu
like symptoms (may also
work between facilities)
2. Take flu vaccine only and return to
work in 2 weeks or when outbreak Is
declared over
Notes:
* if influenza isolates differ than what is contained in the
influenza vaccine for the current season, recommendations
for vaccinated staff may differ
** If unimmunized staff choose to work at another facility,
they must wait one incubation period (i.e. 72 hours) after
working the last shift at the outbreak facility
*** Definition of staff: All persons who carry on activities in
the long term care facility, including but not limited to
employees, volunteers, students, attending physicians, and
both health care and non-health care contract workers
3. If influenza vaccine is medically
contraindicated or refused; take antivirals
only and return to work. Antiviral must be
taken for the duration of the outbreak.
4. Refuse options 1, 2 and 3 above: must
remain off work until outbreak is declared
over
Although the Public Health Department would prefer to have facilities voluntarily respond to the above recommendations,
here is legislative authority under Section 22 of the Health Protection and Promotion Act to exclude staff from work who
wish not to comply with vaccination or antiviral agents.
Niagara Region Public Health
Outbreak Management
23
REVISED October 2012
(iii)
INFLUENZA OUTBREAK MANAGEMENT
When a positive isolate of Influenza A or B is received, an outbreak of influenza will be
confirmed and the following recommendations will be reviewed with your facility by
Public Health staff. To reduce the impact of influenza and ensure that residents and staff
are protected from possible exposure to and transmission of influenza during an outbreak,
the following actions are recommended (see Summary Table below):
Antiviral Prophylaxis (Prevention)
Antiviral medication for prevention (prophylaxis) shall be given to all residents,
whether vaccinated or unvaccinated, and to all unvaccinated staff members.
Currently recommended medications for prophylaxis are neuraminidase inhibitors
–oseltamivir (Tamiflu TM) and zanamivir (RelenzaTM). Oseltamivir (Tamiflu TM)
is the recommended drug of choice for both prophylaxis and treatment in
influenza outbreaks.
Consult with pharmacy for prophylactic dosage
recommendations for residents (ideally, this is done pre-influenza season). NACI
does not recommend amantadine for prophylaxis for this season.
Prophylaxis should be given until the outbreak is declared over. Antiviral
medication may be ordered for 14 days initially and repeated if the outbreak lasts
longer than 14 days. Facilities may wish to consult with their pharmacy
representatives.
Prescriptions of neuraminidase inhibitors, as for all other medications for
residents are the responsibility of the medical directors or attending physicians of
the residents.
For staff, prescriptions of neuraminidase inhibitors are the responsibility of staff
member’s family physician. Offer Sample Letter to Physicians (see Appendix)
for staff to take to their physician which reviews the recommendations.
Antiviral Treatment
For residents who have been ill for <48 hours, antiviral medication for treatment
should be given.
Consult with pharmacy regarding treatment dose
recommendations for residents.
Treatment decisions are the responsibility of the attending physicians.
Oseltamivir (Tamiflu TM) is the recommended drug of choice for both prophylaxis
and treatment in influenza outbreaks.
Treatment must be started within 48 hours of onset of symptoms to be effective
and may decrease the rate of complications.
For residents who have been ill >48 hours, consult with Medical Advisor to
determine if antivirals are appropriate.
Staff Recommendations
(refer to Sample “Recommended Policy Statement for Influenza Outbreaks”)
Staff immunized with influenza vaccine at least 2 weeks prior to the outbreak may
continue to work as long as they are not symptomatic with flu-like symptoms;
immunized staff may also continue to work between facilities
Unimmunized staff have 3 options:
Niagara Region Public Health
Outbreak Management
24
REVISED October 2012
1) Take antivirals AND receive flu vaccine and return to work; antiviral
medications need to be taken for 2 weeks minimum or until outbreak is
declared over, whichever comes first
2) Take flu vaccine only and return to work in 2 weeks or when outbreak is
declared over
3) If influenza vaccine is medically contraindicated or refused, take antivirals
only and return to work; antiviral medication must be taken for the duration of
the outbreak
If options 1, 2 and 3 are refused, then staff must remain off work until the
outbreak is declared over. Note: If unimmunized asymptomatic staff chooses to
work at another facility, they must wait one incubation period (72 hours) after
working the last shift at the outbreak facility.
Note: It is reasonable to allow staff to work with residents as soon as they start
antiviral prophylaxis.
Summary of Outbreak Recommendations:
Antiviral Medication for Prevention and Treatment of Influenza A & B
RESIDENTS
Recommendation
Lab confirmed case of Influenza A or B
Antiviral treatment dose for 5days
Symptomatic <48 hours, but not lab
Antiviral treatment dose for 5 days, then
confirmed
switch to antiviral prophylaxis dose for the
duration of the outbreak
Symptomatic > 48 hours, but not lab
Consult with Medical Advisor to determine
confirmed
if antivirals are appropriate
Asymptomatic regardless of their
Antiviral prophylaxis for the duration of
vaccination status
the outbreak
Residents on antiviral prophylaxis who
Switch to antiviral treatment dose for 5
become symptomatic
days
STAFF
Recommendation
Staff immunized > 2 weeks prior to the
May continue to work if asymptomatic
outbreak
Unimmunized staff
1. Take antivirals AND receive flu vaccine
and return to work; antivirals need to be
taken for 2 weeks minimum or until the
outbreak is declared over, whichever
comes first.
2. Take flu vaccine only and return to work
in 2 weeks, or when outbreak is declared
over.
3. If flu vaccine is medically
contraindicated or refused – take
antivirals only and return to work.
Antiviral must be taken for the duration
of the outbreak.
*Refuse options 1, 2 and 3 must remain off
work until the outbreak is declared over
Niagara Region Public Health
Outbreak Management
25
REVISED October 2012
1.11 RESPIRATORY OUTBREAK ASSOCIATED ORGANISMS:
A Reference Chart For Health Care Workers
ORGANISM
Influenza
Type A or B
SYMPTOMS
Sudden onset of fever,
chills, muscle aches,
headache, runny nose,
sore throat, dry cough
Parainfluenza
Type 1, 2, 3
and 4
cold: stuffy nose, cough

1 to 3 days
PERIOD OF
COMMUNICABILITY
24 hours before onset of
symptoms and up to 3 to 5 days
after onset of symptoms for
adults, up to 7 days in young
children
**Not related to the
virus which causes
influenza
Person-to-person by droplet
and direct contact or
exposure to contaminated
environmental surfaces
2 to 8 days, average
4 to 6 days
person-to-person by droplet
and direct contact or
exposure to contaminated
environmental surfaces
2 to 6 days
3 to 8 days, but virus shedding
may last longer in young infants
and in immunosuppressed in
whom it may continue for 3 to 4
weeks
VACCINE
Nasopharyngeal
Swab (virus testing)
Flu vaccine
Protects against
Influenza A or B
Rapid Test (1 hr)
Nasopharyngeal
Swab (virus testing)
Rapid Test (24
hours)
Type 1: average 4 to 7 days
after onset of symptoms
Virus Culture (7
days)
Nasopharyngeal
Swab (virus testing)
Type 3: average 8 to 9 days
Rapid test (1 hour)
Runny nose, sore
throat, mild to moderate
fever, pneumonia and/or
bronchiolitis
Fever, runny nose, sore
throat
DIAGNOSIS
Virus Culture (7
days)
Pneumonia and
bronchiolitis can
develop in the elderly
Less common cause
of outbreaks
Adenovirus
Person-to-person by
droplets (coughing and
sneezing) and direct contact
with virus contaminated
surfaces (doorknobs, etc.)
INCUBATION
(Note: elderly
population may not
always develop fever)
Similar to a common
Respiratory
Syncytial
Virus (RSV)
MODE OF
TRANSMISSION
Recommended
annually
Vaccine
available for
high-risk
infants/children
No vaccine
Virus culture (7
days)
Person-to-person by droplet
and direct contact of
exposure to contaminated
environmental surfaces
2 to 14days
During the first few days of
illness and shedding continues
for longer periods, even months
Nasopharyngeal
Swab (virus testing)
No vaccine
Person-to-person by droplet
and direct contact of
exposure to contaminated
environmental surfaces
12 hours to 5 days,
usually 48 hours
24 hours before onset of
symptoms and for 5 days after
onset
Nasopharyngeal
Swab (virus testing)
No vaccine
 Asymptomatic
infections are common
Most frequent cause
of the common cold
Rhinovirus
Runny nose, sore
throat, sneezing, watery
eyes, fatigue, fever is
uncommon
Niagara Region Public Health
Outbreak Management
Virus Culture (7
days)
26
REVISED October 2012
WEBSITES WITH INFORMATION ABOUT INFLUENZA
1. www.health.gov.on.ca - Ministry of Health and Long Term Care
Current health issues. Updated regularly.
2. http://www.oahpp.ca/resources/flubulletin.html
The Ontario Influenza Bulletin – the most useful site for Ontario specific data
on influenza. These are published weekly for the province and have region
specific data for nursing home outbreaks, sentinel physician activity and
laboratory testing.
3. http://www.phac-aspc.gc.ca/fluwatch/index-eng.php
Public Health Agency of Canada web page on influenza surveillance.
Updated every two weeks, with data on laboratory results for respiratory virus
identification, and influenza activity across Canada
4. www.oma.org/
Up to date information on influenza
5. http://www.phac-aspc.gc.ca/naci-ccni/
Current Canada Communicable Disease Reports (CCDR)
6. http://www.sanofipasteur.ca
Sanofi Pasteur web page for flu product monograph
7. http://www.gsk.ca
GlaxoSmithKline web page for flu product monograph
8. http://www.novartis.ca
Novartis web page for flu product monograph
9. http://www.niagararegion.ca/living/health_wellness/disease-prevent/flu-clinicschedule
Niagara Region – Public Health web page
Niagara Region Public Health
Outbreak Management
27
REVISED October 2012
ENTERIC OUTBREAK
2.1
SURVEILLANCE – LINE LISTING FORM
See attached line listing forms, and sample on “Completing an Outbreak Line List”:
LTCF – Respiratory/Enteric
Acute Care – Respiratory/Enteric (Residents)
Acute Care – Respiratory/Enteric (Staff)
A surveillance system for enteric illness is an essential component of an institutional
infection control program and will provide the necessary information on baseline rates
and early recognition of an outbreak. Designated staff should initiate a line listing with
details that include onset date, unit/floor location and sign/symptoms. Plotting cases on
the institution’s floor plan is a useful tool for determining if, how and to what extent the
illness is spreading within the facility.
Designated staff should continue to maintain and update the line listing on a daily basis.
Staff should provide updates to Niagara Region Public Health, Infectious Disease
Program on a daily basis by fax. Staff is often reluctant to provide details about personal
illness. This information is often critical to effective outbreak management.
Symptomatic staff are also good candidates for submitting laboratory samples.
Niagara Region Public Health
Outbreak Management
28
REVISED October 2012
2.2
OUTBREAK DEFINITION
An outbreak should be suspected anytime that illness exceeds the normal baseline
distribution in a given area, at a given time. Reporting of enteric outbreaks is
legislatively required under the Health Protection & Promotion Act (HPPA) from the
following institutions: nursing homes, homes for the aged, acute and chronic care
hospitals operating under the Public Hospital Act. Although not required under the
HPPA, reporting of enteric outbreaks in retirement homes is strongly recommended.
Suspect an enteric outbreak whenever there are a greater than expected number of
cases of enteric illness occur on a given unit or throughout the facility among
patients, residents, and staff. The decision as to whether an outbreak has occurred
depends on the population and the usual frequency of the illness in the particular
population. It is necessary to have relevant data on the incidence of enteric infections in
the facility compiled regularly through ongoing surveillance.
Determining if an outbreak exists:
Compare rate of illness with baseline
Check for any other causes of illness (i.e. Laxative Use)
If cases are above the expected number and an alternate cause cannot be
determined, an outbreak exists.
All enteric outbreaks in institutions are reportable regardless of whether they are caused
by:
A reportable agent (e.g., salmonella, E.coli)
A non-reportable agent (e.g., Norovirus)
An unknown cause
Niagara Region Public Health
Outbreak Management
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REVISED October 2012
(SAMPLE) OUTBREAK MANAGEMENT SUMMARY
CHECKLIST
CHECKLIST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Notify charge RN, Infection Control Practitioner or Director of Resident
Care or Associate Director of Resident Care.
For evenings and weekends, notify the manager on-call.
Initiate a line listing of all symptomatic patients/residents/staff using the
Public Health line list form.
Notify Public Health, Infectious Disease Program 905-688-8248 ext. 7330
or after hours 905-984-3690. Have the following information available:
Date of onset / signs and symptoms
Total # of patients/residents/staff in unit or facility
Total # of patients/residents/staff ill at present
Total # of patients/residents/staff immunized against influenza
(for upper respiratory outbreaks only)
Enteric/nasopharyngeal swab kits on hand (check expiry date)
Have Outbreak Management Manual available for reference.
Obtain an outbreak number.
Establish outbreak case definition.
Implement outbreak control measures. Refer to Outbreak Management
Manual for specific respiratory or enteric outbreak control measures.
Place outbreak signs in appropriate areas:
□ Front entrance
□ Stairwells / Elevators
□ Outbreak unit
Cohort and isolate symptomatic patients/residents and place proper
signage on door of room.
Cohort staff.
Collect and refrigerate nasopharyngeal swab or enteric specimens as
directed by Public Health. Contact Infectious Disease Program for
pickup.
Notify:
□ Medical Advisor/MRP physician for facility
□ Administrator
□ Housekeeping
□ Dietary
□ Pharmacy
□ O.T., P.T., Recreation Therapy, Volunteer Co-ordinators
□ Pastoral Care
Notify other units of outbreak and heighten surveillance of ill
patients/residents.
Educate patients’/residents’ family members of limited visitation,
adherence to outbreak control measures and appropriate use of PPE if
needed.
Fax the line listing daily to Public Health, Infectious Disease Program
905-682-6470.
Niagara Region Public Health
Outbreak Management
30
Nurse
Initial
REVISED October 2012
2.3
CASE DEFINITION
Case definitions are outbreak specific and must be developed at the onset of each
outbreak. A case definition for the outbreak will be developed on the initial call to the
Public Health. The definition will be a collaborative effort of the Public Health staff and
the Infection Control Professional or designate of the facility based on clinical
manifestations.
Initially a case definition should be general to all persons who could potentially have an
enteric infection. As the outbreak progresses, the case definition can be revised to
become more specific.
For example, at the onset of the outbreak investigation, the case definition may read:
“A resident/patient or staff member shall be considered a case if he/she exhibits the
following symptoms: 2 or more bouts of nausea, vomiting, and/or diarrhea within a 24
hour period”.
To be defined as a case within a gastroenteritis outbreak, at least one of the following
must be met:
Two or more episodes of loose/watery bowel movements (conforms to the shape of
the container) within a 24-hour period, or two or more episodes of vomiting within a
24-hour period.
OR
One episode of loose/watery bowel movements (conforms to the shape of the
container) and one episode of vomiting within a 24-hour period
OR
Laboratory confirmation of a known gastrointestinal pathogen and at least one
symptom compatible with gastrointestinal infection – nausea, vomiting, diarrhea,
abdominal pain or tenderness.
Note: Consult with your Medical Director prior to collecting any specimen.
Niagara Region Public Health
Outbreak Management
31
REVISED October 2012
2.4
SPECIMEN COLLECTION
Enteric Outbreak Kit
Instructions for the collection and transportation of enteric specimens (faeces)
Obtain Supplies, Complete Requisitions; and Label all Specimen Vials
1) Check expiry date, do not use expired kits.
2) Remove the specimen collection vial(s) from the biohazard bag.
3) Complete an “Enteric Disease Investigation Multiple Specimen Submission Form”.
Include the outbreak number which is assigned by Niagara Region Public Health Department
(NRPH).
4) On the main kit label located on the biohazard bag, fill in the required information with a pen (see
example on reverse). Peel this label off of the bag and place this label on the completed submission
form in the following areas;
a) In the column marked “label” on the “Enteric Disease Investigation Multiple Specimen
Submission Form”
5) Record on each vial used
Patient/Resident Name (First & Last)
Date of Birth (DOB)
Outbreak # assigned by NRPH
6) Peel off 1 of the 4 corresponding kit numbered stickers located on the biohazard bag. Place 1
sticker on each vial used.
**Important: If the patient/resident name and kit number sticker are not on each of the vials,
the specimen will not be tested.
Collect Specimen
Faeces that have been in contact with water in toilet are unacceptable.
7) Using the spoon from each vial, select different sites of the faeces specimen, preferably blood,
mucus or pus, and transfer to the vials as follows:
a) Virology/Toxin (White capped vial which is empty) Add faeces up to the line indicated.
Replace and tighten cap.
b) Bacteriology (Green capped vial with red-coloured transport medium) Add 2-3 spoonfuls, mix
into the transport medium. Replace and tighten cap.
c) Parasitology (Yellow capped vial with clear liquid preservative) Add faeces up to the line
indicated. Mix well. Replace and tighten cap.
Transportation
8) Place all vials in the biohazard bag. Place the completed requisition in the outside pocket. Do not
place the requisition inside the biohazard bag containing the specimens.
9) Refrigerate specimens immediately. Do not freeze specimens.
10) Call the Infectious Disease Program as soon as possible to pick up specimens.
**See next page for Labelling Example
Niagara Region Public Health
Outbreak Management
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REVISED October 2012
Labelling an Enteric Outbreak Kit
Enter date
specimen
collected
Enter case
name & date
of birth (DOB)
Enter onset
date of case
symptoms
Enter health
card number
Outbreak #
2246-201X-XXX
Place one sticker on each vial used
Niagara Region Public Health
Outbreak Management
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REVISED October 2012
Outbreak Number
Provided by Niagara
Region Public Health
2246-year-3digit number
Your Facility
Name
Address
Telephone/
Fax Number
For Lab Use Only
Affix Completed Main Kit Label Here
Niagara Region Public Health
Outbreak Management
34
REVISED October 2012
2.5
FOOD SAMPLING GUIDELINES
The purpose of these guidelines is to provide a standardized method of collecting
samples of hazardous and high risk foods from meals in institutional kitchens as a
precaution in the event of a food-borne disease outbreak. They also ensure that the
laboratory would receive samples of adequate quality and quantity.
HAZARDOUS FOOD
Is defined as “any food that is capable of supporting the growth pathogenic organisms or
the production of the toxins of such organisms”. Such foods typically include milk, milk
products, eggs, meat, poultry, fish and shellfish. For example: Breakfast: Eggs;
scrambled or that have had additional handling and processing. Lunch/Supper: All
entrees, sandwich fillings, all sauces, soups gravies; anything containing mayonnaise,
salad dressing, i.e., potato, macaroni salad. Any dessert product containing milk, cream,
whip cream topping. Vegetables combined with creamed sauces.
Samples of each potentially hazardous and high risk foods should be taken at every
meal and retained by the institution for a period of not less than 5 days. Foods that are
further processed should also be sampled (i.e., pureed roast beef). Samples may be kept
in the refrigerator or freezer.
SIZE OF SAMPLE
Solid Food- Minimum 100 grams.
Liquid Food-Minimum 100 mL.
CONTAINER
Must be sanitized food containers or self-closing plastic bags.
LABELLING
Contents (i.e. pureed roast beef)
Date of meal (i.e. February 25, 1992)
Time of meal (i.e. 5:00 p.m.)
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2.6
INFECTION PREVENTION AND CONTROL MEASURES
Facilities that suspect they have an outbreak should implement initial outbreak control
measures to prevent further spread of illness. Facilities should consider establishing an
Outbreak Management Team and meet regularly including all representatives who
have decision making authority in the facility. Members should include:
Medical Advisor/Director
Administrator
Director of Nursing/Director of Resident Care
Infection Control Officer/Infection Control Nurse
Public Health Nurse/Public Health Inspector
Housekeeping/Laundry Supervisor
Food Services Supervisor
Recreational Activities Supervisor
The following infection prevention and control measures are recommendations for
management of enteric outbreaks from Public Health.
NOTE: For confirmed CDI outbreaks, not all control measures as outlined below may
apply. Consult with Public Health for specific recommendations for control of CDI
outbreaks in health care facilities.
1. Isolation of Symptomatic Cases
Cases should be isolated in their rooms for 48 hours from the cessation of
symptoms as long as this does not cause them mental or physical harm
Implement contact precautions (i.e., post signs)
http://ricn.on.ca/photos/custom/CSICNfiles/Contact%20STOP%20Sign_Front%20&%20Back.pdf
Optimally, room isolation should be used but if this is not feasible, ward/unit
isolation could be applied
No restriction is required for asymptomatic roommates of cases, however as much
as possible, restrict all residents to their units
2. Cohorting Residents/Staff
Cohorting is defined as the grouping together of individuals in a specific area to
limit the contact between infected cases and non-infected cases, in order to
decrease opportunities for transmission of infectious agents
If possible, exposed staff should remain caring for symptomatic cases on a daily
basis and avoid transferring to another unit/floor during the outbreak
Strict cohort nursing is not always possible when many staff are ill
Allied health professionals (e.g., respiratory therapists, physiotherapists,
occupational therapists, speech therapists, recreational therapists) should be
cohorted to the outbreak unit where possible, or provide care on non-outbreak
units before entering the outbreak unit (preferably on a one-on-one basis)
3. Hand Hygiene
To facilitate staff and visitor hand hygiene, hand hygiene stations should be set up
at designated areas in the facility (i.e., entrances, outside elevators,
patient/resident care areas)
Hand hygiene should be performed:
o Before initial patient/resident or patient/resident environment contact
o Before sterile procedures
o After body fluid exposure risk
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4.
5.
6.
7.
8.
o After patient/resident or patient/resident environment contact
Alcohol based hand rubs (ABHR) are the first choice for hand hygiene in clinical
situations when hands are not visibly soiled. Using ABHRs is more effective than
washing hands (even with an antibacterial soap) when hands are not visibly
soiled. When visible soil is present and running water is not immediately
available, use moistened towellettes followed by ABHR.
Residents, staff and volunteers should be instructed in proper hand hygiene to
facilitate staff and visitor hand hygiene. Refer to Appendix: “Hand Hygiene using
Hand Rubs”
Gowning/Gloving if Contact with Contaminated Material is likely
The use of gowns and gloves is recommended for direct patient care of ill
residents during an outbreak to prevent transmission of organisms
Visitors do not need to wear gloves or gowns if they are visiting one resident
only; however, if providing direct resident care to an ill resident they should be
encouraged to wear a gown and gloves and should be asked to wash their hands
before and after the visit.
Refer to Appendix “Sequence for Donning and Removing Personal Protective
Equipment.”
Enhanced Environmental Cleaning/Sanitizing
Ensure cleaning and sanitizing of environmental surfaces frequently contaminated
by residents/staff (i.e. hand rails, door knobs, bathroom units, furniture)
Ensure a process for proper disposal of contaminated materials
Cleansing and sanitizing methods should be reviewed by Public Health Inspector
Disposable dishes and cutlery are not required
Refer to: PIDAC Best Practices for Environmental Cleaning for Prevention
and Control of Infections and Best Practices for Cleaning, Disinfection and
Sterilization of Medical Equipment/Devices
Exclusion of Symptomatic Staff from Work/Facility
Staff who meet case definition are excluded from the facility until they have been
48 hours symptom free (i.e. food handlers, health care workers including
volunteers and students)
Limited Visiting
Signs should be posted in the facility indicating that there is an outbreak and
visitors should be warned that they may be at risk of acquiring infection within
the facility
During an outbreak, visitors should visit only their own friend/relative, in their
own room (not in a common area), and should be encouraged to wash their hands
before and after the visit at hand hygiene stations in the facility
Public Health does not recommend closing the facility to visitors/volunteers.
Only in the case of extremely virulent disease would the Medical Officer of
Health order the facility to be closed to the public. See Appendix: What You
Need to Know About Outbreaks.
Suspension of Social Activities
As much as possible, restrict activities to their respective units. The Outbreak
Management Team must find a balance between restricting activities and to
control the spread of infection and providing therapeutic opportunities from social
activities.
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Visitation by outside groups, e.g., entertainers, meetings, community groups, etc.,
is not recommended. Also, visitation of multiple residents is not recommended.
Onsite adult and childcare programs may continue provided there is no interaction
between residents and participants of the program.
9. Restrict New Admissions, Re-Admissions and Transfers
Restricting admissions unnecessarily will create a backlog in acute care or other
community facilities; on the other hand, admitting persons who are susceptible
into an outbreak situation poses a risk to their health
Residents can be transferred from the outbreak facility to a hospital with prior
notification to Hospital Infection Control Officer or designate
Residents admitted from the outbreak facility to hospital with enteric illness
can be re-admitted to the LTCF at any time, provided that appropriate care can be
given.
New admissions (from community), residents admitted to hospital prior to
the outbreak, or admitted to hospital for reasons other than enteric illness
may be admitted/re-admitted to the LTCF if the following conditions are met:
(a) the resident or substitute decision-maker has been informed of the outbreak
status and provided consent;
(b) the residents physician has been informed of the outbreak status and provided
consent (taking into consideration the severity of the particular outbreak
relative to the residents condition)
Resident transfers from anywhere in the facility to another Long Term Care
facility is not recommended during an outbreak. Possible exception of this
recommendation should be discussed with the Medical Officer of Health on
an individual basis.
10. Advise Hospital Infection Control Staff of Outbreak Prior to Transferring a
Resident
Prior to transfer of residents to hospital, designated staff at the outbreak
facility should contact the Infection Control Professional directly by phone to
inform them that the resident is coming from an outbreak situation
Inform them of the outbreak, the pathogen if known, and if the resident is
symptomatic or not
11. Working at Other Facilities
During enteric outbreaks, staff/volunteers should not work at any other
facility. If asymptomatic staff chooses to work at another facility, they must
wait one incubation period (i.e. 48 hours) after working the last shift at the
outbreak facility (if the causative organism is known, the waiting period may
differ). Staff working at 2 facilities must inform the receiving DOC (Director
of Care) or designate at the non-outbreak facility.
12. Medical Appointments
Non-urgent appointments made before the outbreak shall be rescheduled.
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ENTERIC OUTBREAK
CONTROL MEASURES
The following control measures are in force until further notice:

Isolation of symptomatic cases

Cohorting residents/staff

Hand Hygiene

Gowning/gloving if contact with contaminated material is
likely

Enhance environmental cleaning and sanitizing

Exclusion of symptomatic staff from work

Limited visiting

Suspension of social activities

Restrict new admissions, re-admissions & transfers

Advise Hospital Infection Control Staff of the outbreak
prior to transferring a resident/patient

No food from outside sources

Staff/volunteers should not work at another health care
facility
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2.7
DECLARING OVER
The Medical Officer of Health or designate, in collaboration with the Outbreak
Management Team determine when to declare an outbreak over, taking into consideration
the enteric organism causing the outbreak.
An outbreak of unknown etiology where the symptoms are consistent with a viral
illness can be declared over 48 hours from the cessation of symptoms of the last
resident case.
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2.8 ENTERIC OUTBREAK ASSOCIATED ORGANISMS:
A Reference Chart For Health Care Workers
ORGANISM
SYMPTOMS
MODE OF
TRANSMISSION
INCUBATION
 Gastrointestinal (diarrhea)
 Fecal-oral route
 3 to 10 days
 Diarrhea, abdominal
cramps, fever may occur
 Fecal-oral route
 Unknown
PERIOD OF
COMMUNICABILITY
DIAGNOSIS
 Most communicable during the  Stool specimen
first few days of an acute illness
Adenovirus
 Contact with
contaminated
environmental surfaces
Clostridium
difficile
 Symptoms characteristically
last 24 to 48 hours
 Probably by the fecal-oral
route
 24 to 72 hours
 During the acute stage of
disease and up to 48 hours after
Norwalk diarrhea stops
 Stool specimens
 24 to 72 hours
 During the acute stage of
disease, and later while virus
shedding continues
 Stool specimens
 Contaminated food or
water
 Exposure to contaminated
surfaces and vomitus
 Vomiting, fever, and watery
diarrhea (severe)
Rotavirus
 Stool specimen
from
patient/resident
with diarrhea
 *Rectal swabs are
not accepted and
will not be tested
 Diarrhea, nausea, vomiting,
cramps, headache, fever,
chills, malaise
Norovirus/
Norwalk-like
Virus
 Until formed stools
 Symptoms last for an
average of 4 to 6 days
 Probably fecal-oral with
possible contact or
respiratory spread
 Virus is not usually detectable
after the eighth day of infection
**Most common in daycare
outbreaks
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APPENDIX
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Outbreak Management
SAMPLE TRANSFER LETTER
Please be advised that _______________________________ is being transferred from a
Name of Resident
Facility where there is as suspected OR confirmed influenza outbreak. Please ensure
that appropriate isolation precautions are taken upon receipt of this resident.
At the time of transfer, this resident was confirmed OR suspected OR appears free of
influenza.
Resident is on antiviral medication ________________________ starting on
___________________. Dose of the medication ___________________
Resident’s vaccination status is: pneumococcal yes______
Influenza
yes______
no ______
no ______
For further information, contact _______________________, Infection Control
Name of Infection Control Practitioner
Professional at __________________________________________
Name of Facility
at ____ ____- ___________
Phone Number
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Outbreak Management
SAMPLE LETTER TO PHYSICIANS
Dear Doctor
______________________ (staff member’s name) is an employee currently working in a
Long Term Care Facility that has a confirmed Influenza A/B outbreak. It is
recommended that the employee receive antiviral prophylaxis before returning to work.
The recommended antiviral medications of choice for prophylaxis during influenza
outbreaks is:
Oseltamivir (Tamiflu™)
75mg. daily x 14 days or until outbreak is declared over
OR
Zanamivir (Relenza™)
Two 5 mg inhalations (10 mg) once daily for a minimum of 2 weeks or
until the outbreak is declared over
If you have any questions, please contact Niagara Region Public Health, Infectious
Disease Program at 905-688-8248 ext 7330.
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Outbreak Management